Focus, starting, and ADHD

Good help leaves you more able to do it yourself next time. If the whole thing only works while the other person is in the room, something has gone sideways.

There is a real difference between someone building your schedule for you and someone sitting beside you while you build it. The second is slower and…

If a course has no fixed time, give it one. Write down which day and which hour you will watch it, put that in the calendar as though somebody else set it, and tell one person.

Five minutes every Sunday: when am I watching this, and when am I doing the work that comes after it. Then one short message midweek to whoever is…

When you agree to something, agree who follows up. Do you tell them if it slips, or do they check in with you?

Most of the hurt around late work comes from nobody having said. You assume they will ask, they assume you will speak up, and the silence in between…

Tell your partner, on a good day, that the things you say at full volume are not a fair record of what you think. Not as an excuse. As information about how you work.

It changes what lands. If they know in advance that the heat is real but the words are unreliable, they can wait for the version that arrives twenty…

Hypervigilance after trauma and ADHD scanning look much alike from outside. Often the honest answer is that both are present, and the real question is how much of each.

Watching that comes from threat is aimed at something and tends to switch on in particular situations. ADHD distraction is not fussy about where it…

Damage to the front of the brain can produce something that looks a great deal like ADHD: poor impulse control, blunted judgement, a person their family says has changed.

The nineteenth century railway worker who survived an iron rod through the frontal lobes is the standard illustration, and what altered in him was…

Not every bout of eating too much belongs to an eating disorder. Ask whether how the body looks is part of it, because that is where the two paths separate.

When bingeing comes out of ADHD it is often boredom, or the food simply being there with nothing stepping in to stop it, and the person is not…

When you need a date, hand people events rather than months. Was that before or after the holiday? Same year as the move?

Asking whether something happened between October and January invites a guess. Asking whether it was before or after a wedding, a house move or a…

Ask for a number first, then go hunting for exceptions. How is today on a scale of one to ten, and when was it last higher than that?

An assessment can turn into an hour of everything that is wrong, which leaves a person flatter than when they arrived. Exception questions do the…

Find out what they have tried before that did not work. It saves everybody from a plan that failed this person two years ago.

Most people arriving for an assessment have been trying things for years: apps, alarms, lists, an early night, a course somebody recommended.…

Run a short anxiety and depression screener alongside the ADHD measure at every intake, not only when someone mentions their mood.

Mood and anxiety sit beside ADHD often enough that leaving them out means guessing about the concentration difficulty in front of you. Doing it as…

A tick beside 'does your mind race' means less than it looks like. Someone whose mind has raced since they were nine has nothing to compare it against, so ask what changed and when before you let the score speak.

Take the endorsed items one at a time and put a period of time around each one. When did this start? Was there ever a stretch when it was not there?…

Both people will tell you they were up for three nights. The useful question is what they did with those hours: driven and busy points one way, wired and wrecked points another.

In mania the need for sleep falls away and the activity has a purpose behind it, however unrealistic that purpose looks from outside. In ADHD the…

Ask twice. First, who in the family has an actual diagnosis. Then, who do you look back on now and wonder about. The second question nearly always brings more than the first.

Plenty of families never went near a clinic. Help was not trusted, or the answer at home was to stop complaining and get on with it, so the…

A child who grew up listening for a parent's seizure learns to keep half an ear on the room, and years later that can look a great deal like distractibility. Ask what they were listening out for as a child.

This turns up most often where there was one parent and nobody else to keep watch. The person cannot settle, cannot stay with a task, and has assumed…

Alongside diagnoses, ask how relatives died. Falls from roofs, crashes, deaths with the safety gear left on the ground: these recur in some family lines and they say something a list of diagnoses cannot.

Ask it gently and let people take their time, because you are asking about grief as much as about pattern. What you are listening for is a habit of…

The relative who was shut in a cupboard, tied to a chair or expelled was being managed for the same thing you are assessing now. There was simply no name for it then and no help attached to it.

Told carefully, this changes the story a family tells about itself. Not a line of difficult people, but a trait that has been present for generations…

Before you decide a strategy has failed, check whether the medication underneath it is doing its job. If someone is sitting in front of you still struggling, the honest first answer is usually that it is not, quite.

Ask about the shape of the day rather than the dose alone. When does it come on, when does it wear off, which hours are the hard ones, is there any…

Before handing anyone a new system, make sure they can say back why it should work better than what they are doing now. A strategy with no reason attached gets dropped the first time it is inconvenient.

Ask them to explain it to you in their own words and listen for whose reason it is. If the logic is only yours, it will hold for about a week. It is…

Ask what they think this will cost them in effort, then say what you think. People rarely give up because a strategy failed. They give up because it turned out to be harder than anyone had told them.

Be specific about the first fortnight, since that is when it is worst and the payoff has not arrived yet. Someone who expected a small effort and met…

When something did not get done, find out which half broke. Did they not know what to do or when? Or was the plan fine, and the moment for doing it came and went?

Ask for the last time it happened, hour by hour, up to the point where it did not happen. A planning failure needs somewhere reliable to catch tasks…

Awareness is knowing what needs doing and when. Motivation is doing it once you know. Nearly every app on the market solves the first one, which is why buying another one so rarely helps.

Test it with one question: at the moment it did not happen, did you know? If the answer is yes, the reminder was never the missing piece, and a…

Carry the rough proportions into every ADHD assessment. Executive function difficulty in the great majority, coordination difficulty in around half, dyslexia in something like a quarter to two fifths. A workup that never asks about handwriting, sport or reading is not finished.

The behaviour problem you were called about is often the visible end of an unidentified reading or coordination difficulty. Ask what PE is like, what…

Parents with one affected child often ask what they might do differently before the next one. Answer honestly: there are lists of suggestions in circulation, the evidence behind most of them is thin, and the question underneath is usually about blame.

Take the question seriously and take the guilt seriously alongside it. Give what is genuinely known, say plainly where recommendations run ahead of…

Keep the tasks short, a couple of minutes each, with results back the same day. A long test given to a child who cannot sustain attention measures how long they can last, not the thing you were trying to measure.

Brevity is not a convenience you are allowing yourself. It is what keeps the data honest, and it keeps the child willing for whatever you ask next.…

Clapping games, skipping rhymes and silly verses are worth doing. They are good for the ear and they cost nothing, but they will not on their own repair a reading difficulty, and it is kinder to say so early.

Play the games, and separately get the structured teaching that a child with a real decoding problem needs. Families are often told that rhyming…

Invent words together. Say a made up word, pull it apart into its sounds, put it back, then take one sound out and hear what is left. The nonsense is the point, because there is nothing for memory to fall back on.

With a real word, a child who cannot work with sounds can often get by on memory, and you learn nothing about what they can actually do. A made up…

Plenty of children read the equals sign as put the answer here. Write it the other way round sometimes, eight equals three plus five, so they meet the idea that both sides are simply the same amount.

Move the sign about. Leave the gap in the middle, four plus something equals two plus five, and watch what the child does with it. If they add…

The word one does several jobs at once: a digit, a number, a single object, a whole set. A child who has not sorted those out will put figures in the wrong columns and later read a third as a number instead of a part of something.

When digits land in the wrong place, check whether the child knows what is being counted before calling it carelessness. Say the unit out loud: one…

Ask someone to repeat a made up word and memory cannot rescue them. That is exactly why this small task keeps finding difficulties a clever, well practised person hides everywhere else.

Real words can be recalled, and a strong memory will lift a score without the skill underneath being there at all. A word that has never existed…

Pill swallowing can be taught in a few short sessions with sweets. Start with the tiniest ones, give two to eat for every one swallowed whole, and work up in size across a week.

Keep each session short and cheerful and stop before anyone is upset, since one frightening attempt can set the whole thing back weeks. For capsules,…

Being given a medicine that holds no licence for your condition can feel like being experimented on. Usually it means the evidence is decent but thinner than a licence demands.

Bupropion is the common case. It helps some people with attention difficulties, often alongside a stimulant, and it never gained the indication, so…

Debt, impulsive spending, an account that never quite recovers: this belongs in the conversation about attention rather than in a separate drawer marked shame.

People hide this part longer than anything else, which means it is usually the last thing to get any help. If you are the one struggling, saying it…

Before you explain anything about medication, ask what the person already believes about it. You cannot correct a worry that has never been said out loud.

Most people arrive carrying something: a cousin who could not sleep, a headline, a parent with a strong view. Lead with your own information and you…

In practice the non-stimulants turn up more often as an addition than on their own. A stimulant in the morning with guanfacine alongside it is a common shape.

The two act at different points of the same circuit, so they tend to complement rather than repeat each other, and the blood pressure effect of one…

Where anxiety sits alongside the attention difficulty, a non-stimulant is sometimes the better first choice. Stimulants sharpen anxiety in some people, and that is a hard trade to live with.

The same holds when blood pressure rises on a stimulant that is otherwise working, since adding an alpha-2 agent can make it possible to keep the…

A small short-acting dose in the afternoon, on top of the long-acting one, is ordinary practice rather than a special case. Homework and the evening drive often fall outside what the morning dose still reaches.

The hours when you most need to hold back are frequently the hours the medicine has stopped covering. Raising the morning dose to solve an early…

These are among the best studied medicines in psychiatry, in use for decades. Most of the hesitancy around them traces back to how they get covered in the press rather than to the safety record.

Saying that is not the same as saying there is nothing to watch. Heart rate and blood pressure shift a little, appetite and sleep often need…

For a family stuck on whether to medicate at all, the comparison with diabetes often unlocks something. Nobody manages diabetes on diet alone, and nobody calls insulin a moral failure.

Offered gently it moves the question from what kind of parent am I towards what does this condition need. Played as a trump card it makes people…

Methylphenidate and amphetamine are not two names for the same thing. One mainly blocks dopamine from being taken back up, and the other does that and pushes more of it out as well.

That extra step is why the amphetamines tend to produce somewhat larger average effects, and why somebody who got nothing from one can do well on the…